September 2007

Out of the Office and Into the Dining Room: Dietitian-led Mealtime Support Groups
By Ilyse Simon, RD, CDN
Today’s Dietitian
Vol. 9 No. 9 P. 76

Lily is terrified to eat a slice of pizza and fears she will immediately gain 4 pounds if she does. Tina is anxious at mealtimes and eats by taking tiny bites of her food. She spends more than one hour eating a small snack. Julie is so ashamed of eating that she can’t eat in front of others and binges in secret. Robin has just been released from an inpatient eating disorder facility and is already skimping on her meal plan.

For people with eating disorders, mealtimes can be the most stressful part of the day. Meal preparation, eating, and watching other people eat can trigger negative thoughts and self-destructive behaviors. As practitioners, we know clients benefit from supervised and supported mealtimes. As entrepreneurs, dietitians look to expand their services in creative ways. Dietitians intrigued by these hands-on food experiences are seeking ways to develop their own groups. From one-on-one restaurant outings to larger meal support groups, dietitians are moving out of the office and into the dining room.

Mealtime support is an effective tool used with eating disorders such as anorexia, bulimia, and compulsive overeating. Mealtime support teaches clients to shop for, plan, and prepare appropriate meals. It is a scheduled “rehearsal” in which clients confront their resistance in a facilitated, structured, and supportive environment. These groups build confidence and teach strategies to get through a meal successfully. The group setting provides distraction from eating, prevents clients from isolating, and deters them from purging behaviors. While group meals provide professional supervision by a dietitian, they also present opportunities for peer support from others faced with similar difficulties.

The Professional’s Challenge
From intuitive eating groups to exchange-based meal plans, this modality is challenging for clients and professionals alike. A mealtime support group’s goal is to make eating a normal experience. People with eating disorders can be highly competitive about their weight and food. Participants will compare their meals to what other members are eating. When one member doesn’t bring in what she’s supposed to, it can trigger a revolt and lead to an unmanageable crisis.

Pam Kelle, RD, LDN, CDE, a nutritionist at Solace, an intensive outpatient eating disorder clinic in Chattanooga, Tenn., leads a small (two to six people) group that meets twice per week. Her clients are required to bring their own meals according to an exchange-based meal plan, and Kelle models normal eating behavior by dining with the group. When clients are responsible for their own food, they learn how to plan appropriate meals. Exchanges in Kelle’s group include not only protein and carbohydrate but also calcium, fiber, and vitamin C.

Danielle Paciera, LDN, RD, CCN, of the New Orleans Center for Eating Disorders, runs several small groups mixed among people with anorexia, bulimia, and compulsive overeating. She finds value in intermingling people with different eating disorders. It leads to discussions that put each individual’s struggle in perspective. Paciera says, “There’s often competition with anorexics, but compulsive overeaters tend to be more engaged in the ‘therapy’ and won’t stand for a person who doesn’t finish her meals, bring appropriate meals, or pushes food around.”

When working with clients with eating disorders, one can expect tension when asking a participant to bring a balanced meal. For clients who have severely limited their food choices, it can ignite a skirmish. Experienced dietitians will not engage in the conflict and instead motivate the client and increase her confidence. Kelle says, “One of my clients will only eat carrots, pepperoni, broccoli, tomatoes, and low-carb tortillas. So, that’s what she brings. We run into battles about what she eats, but I don’t want it to be a huge power struggle.” Kelle helps clients choose appropriate exchanges and take small steps to expand their food choices. By using food models, labels, measuring cups, and simple measuring techniques (eg, a fist, computer mouse, deck of cards), participants plan and prepare proper amounts of food.

Planning and shopping for meals can be overwhelming and stressful when under the reins of an eating disorder. Dietitians recognize that taking clients to grocery stores can be an invaluable hands-on approach. Unfortunately, few dietitians take their clients out to eat or to the food store. Though professionals agree that these outings are useful, lack of insurance reimbursement and liability issues deter dietitians from these trips.

However, dietitians are creative. To avoid a liability issue, one dietitian passed up public outings to the food store and instead drafted a model grocery list. This inventory has sample selections from different food groups that help her clients steer through the aisles. She also devotes a group session to restaurant meals. Clients work with real menus and focus on healthy ways to incorporate all types of foods. Dramatization of a restaurant experience serves as a forum for clients to work through their anxiety before actually dining out.

Bruce Brennan, MS, RD, is the nutrition director at the Sol Stone Center for Eating Disorders in Elmira, N.Y., and frequently dines out. He has organized a group that takes members of their partial hospital program to local restaurants. His favorite jaunt is a local grill for burger night. Since having a burger is a requirement for the evening, Brennan’s group talks about the meal before the actual outing. He discusses how to estimate portions and exchanges and schedules time after the meal for further discussion.

As a former chef, Brennan has found how to blend his love for food with his work. He and his group of eight to 10 clients plan a weekly three-course community meal. Participants prep ingredients in the kitchen and cook the meal for themselves and the staff. Participants shoulder the entire responsibility of the event—from table settings to meal presentation. Group members are required to eat everything—from chilled peach bisque and scallops in parchment with grilled polenta and asparagus spears to a finale of roasted pineapple and raspberry sorbet. For some meals, exchanges are given and clients are taught how to “borrow” exchanges from other snacks if needed to balance their day’s intake. To challenge participants, some meals are not defined by exchanges, and clients are taught to estimate portions and judge how the meal fits into their plan.

Brennan used another innovative approach when working on a college campus. Seeing the need for experiential support, he organized a weekly group of roughly four students and joined them to navigate the dining hall. Brennan says, “I coach them how to deal with the dining hall without being triggered. For those who like to measure their foods, I tell them that measuring food is not normal. I train them to keep a visual in their mind, like a deck of cards, which helps them approximate portions. And I require each of them to come with me, or a supportive friend, and have a piece of cake.”

Planning for such forays is imperative. Brennan says, “If students can have a preconceived plan of what they need for their meal, they don’t have to look at every station.” He also stresses the importance of connecting to a supportive ally and resisting the urge to isolate after a challenging meal. He loves the group forum as it provides peer support before, during, and after meals.

Dietitians use many strategies to help decrease anxiety during mealtimes. Creating a peaceful atmosphere can set the stage. Soft music in the background, special lighting, table settings, or a blessing before the meal can transform an eating experience. During the meal, diversions are important to drown out the “voice” of the eating disorder. To distract from eating disordered thoughts, some groups play games or have preset “table topics” for light conversation. Good conversation themes include current movies, travel destinations, foreign languages that are spoken, pets, and hobbies. Therapeutic-aimed questions, such as “What emotions are you bringing to the table?” can help participants recognize their anxiety and feelings before a meal. A hunger/fullness check-in at the beginning and end of the meal is useful to separate mind and body hunger.

After a meal, it is important to process together. Dietitians solicit feedback from the group about anything during the meal that made them uncomfortable. This is an opportunity to ask probing questions about the appropriateness of an individual’s food choices. At the end of a meal group, Paciera leads clients through a debriefing. She says to the group, “I want you to pay attention to how your eating habits might not look normal to someone else.” And then they discuss the specifics. Maybe one person put her fork down after every bite, or another pushed the potato around, or one ate foods in a particular order. This open comment period helps clients recognize their disordered behaviors.

The Mealtime Agreement
Boundaries and rules are essential to this work. Successful dietitians insist on having a written contract signed by participants that clearly outlines what is expected during the group. Ramifications are plainly stated, and most consequences involve dismissal from the group until the rules are met or expulsion from the group entirely. Clearly written rules avoid future conflicts.

Rules can regulate what and how a participant eats. Meals need to include foods that the client enjoys and should be eaten at a reasonable pace. An often-rebuffed rule is the inclusion of a visible fat source. As Paciera says, “If someone uses diet mayo, it usually comes out in group. They need a visible fat source.”

Including a challenge food in a meal is a frequent rule, yet the specific food may be different for each participant. Some clients decide for themselves what to bring as a challenge. If they are having difficulty or bring in a safe food like grilled chicken, the dietitian will spend individual time with them to help them decide what is suitable. Veterans of mealtime groups say it is supportive to eat a full healthy meal with your clients. Clients will be watching to see whether you butter your bread or spread mayonnaise on your sandwich. Modeling appropriate behavior can help normalize mealtimes.

Ideally, the best way to evaluate what a participant brings is to have a check-in before the meal. If someone’s meal comes up short, issue a warning. The first or second occasions can be used as teaching opportunities. When a client does not eat her food, it is wise to ask the client if she feels it is appropriate to be in the group. Paciera has faced this situation numerous times. She is reluctant to kick people out but does suggest “taking a break” from group for those who cannot meet their meal plan. Paciera remarks, “If they consistently cannot meet their meal plan, I refer them to higher level of care.”

Common rules prohibit diet food and the discussion of numbers (eg, calories, weight) or trauma. Discussions that involve models, size, or the nutrient content of foods are not only discouraged but can be grounds for dismissal if consistent. Although clients are encouraged to openly voice their feelings during meals, they are not allowed to comment on their meal, the feeling of fullness, or other triggering topics. These comments are highly disturbing to participants and can be a manipulative tool used to disrupt the group.

What happens when a client engages in eating disordered behavior in the middle of your calm dinner group? For Kelle, it is obvious when these behaviors are being used. She says, “When someone begins chatting nonstop during a meal, they are trying to delay or minimize their intake. They may move food around or tell me they have a date and are not hungry. I point out that their behavior is detrimental to the rest of the clients, and they are responsible for everyone’s experience, not just their own. Some clients learn valuable lessons while watching someone else act out by realizing that their own disorder has upset mealtimes in their past.”

A good strategy is to enlist group members to sort out the situation. Ask people how the situation makes them feel. Usually at least one person will comment about how an individual’s outburst makes the process harder. Let the group openly process so they can see how behaviors are triggering to everyone. It may become clear that refusing to eat is refusing to go forward with recovery. If a member repeatedly creates havoc, she may not be ready to let go of her disorder.

When confronted with an individual who is acting out, Paciera uses the disruption as a learning scenario. She says, “I may take the person aside for five minutes and ask them, ‘What do you need to stay stable right now?’ and remind them that we will talk about this issue later in a private session. I also ask group participants to lend support. If someone feels like purging, I’ll ask others in the group what they do to keep themselves safe.” By eating together, if someone acts out, the group can respond to the situation and talk about other appropriate behaviors. Group members can share what is helpful to them when faced with similar urges. This forum lets group participants lend support to one another.

Even with the best preparation, inappropriate comments during meals are a constant infraction. When the topic of weight arises, experienced dietitians will acknowledge the comment, hone in on the feeling, and remind the entire group about the rules. Then, leaders will redirect the conversation. When clients bring up provoking subjects, notice how the disruption affects the group. Paciera recalls a client who talked about purging her meal. Paciera spoke directly to the individual and said, “I understand what your struggle is, and can you rephrase it as ‘I have the urge to act with my eating disordered behaviors’?” The focus then shifted to the participant’s urge as an extension of her eating disorder rather than the physical act of purging.

Paciera continues, “These patients are competitive. If one says, ‘I’m kind of nervous that I’m under 100 pounds,’ I say, ‘I understand you are scared, but try not to mention weight.’ I then redirect the conversation.” The emotions that a dietitian has when facilitating a turbulent mealtime experience are probably similar to those that clients have during the meal. Managing mealtime conversation can be difficult, but experience, clear guidelines, and distraction techniques can be guides through the most difficult groups
Three Strikes, You’re Out

Kelle noticed a secretive pattern to some clients’ eating behavior. Group members would take their food from their lunch bag one bite at a time so their food was hidden from others. Kelle says, “They like to take a bite of apple and put it back so no one can see them eat.” Kelle has had her clients sign a contract agreeing to rules of conduct. No longer are clients allowed to pull their food apart or hide behind their meal. Kelle says, “Clients must bring in food and make a genuine attempt to eat. I don’t force them the first few weeks. If I have a rigid anorexic, it’s ridiculous to expect her to eat. I try to work in the realm of where they are.” If they do not eat, they must leave the group.

As explicit as her rules are now, it wasn’t always so clear-cut. This year, two of four girls in Kelle’s group refused to bring food. She offered snacks, which were also refused. The entire group was disrupted. Furthermore, the remaining two girls who did bring their food also refused to eat. Kelle was stuck. She thought, “If I kick them out, we lose the group. If I let them do this, it destroys the purpose of the meal group. If I let them just sit there, they get what they want.” Situations like these are common, and clear guidelines will help a group leader through turbulent times.

With the advice of fellow dietitians, Kelle asked the participants who refused to bring or eat food to leave the group. Since then, other people have joined, and the group is a success. This instance spurred Kelle to have the participants sign a food/meal plan contract that specifies appropriate foods and portions. It requires the participants to behave in ways suitable to the group setting. The contract makes it clear that a participant using her eating disordered behaviors would blatantly violate these rules and be dismissed swiftly.

Kelle says that working toward a solution was a long haul. She remarks, “I felt so exhausted. Frankly, it was the most frustrated I have ever felt working in this field.”

If a client refuses to bring or eat appropriate food, supplements or snacks can be offered to compensate for the meal’s shortcomings. If snacks are refused, a refresher on the rules, contractual agreement, and the therapeutic rather than punitive value of the group can be a good reminder to get clients back on track.

Hope on the Horizon
Progress in mealtime groups comes when a client takes responsibility for her recovery. Outpatient programs work for those who are motivated. When clients are unwilling to “work,” it is stressful for the entire group. For Paciera, the most challenging part of her work is the tension. “It can be an unpleasant atmosphere because people don’t want to be here,” she says. Participants will regularly ignore the rules and challenge group leaders. Clients who refuse to meet guidelines need a different level of care, as they can easily disrupt the group.

Eating disorders are taxing on clients and providers alike. For Kelle, the most difficult clients are those who insist that their eating style is a matter of health and is not disordered. It is also a huge setback for everyone in a group when one person speaks inappropriately. Kelle comments, “Some girl will be really trying and bring in a great meal—say, rice and chicken with a vegetable and yogurt—and another client may say, ‘I hate rice. It is so fattening.’ It can devastate everyone involved.”

Paciera says that what makes her group successful is her dietetic background. “Talking about food is one thing, but working hands-on is something completely different. I can help them separate food and feelings while they eat. Often, if they feel anxious during the meal, they associate it with food. I can remind them that they were feeling anxious before we started. It helps them see the anxiety might not be from the food. I help people sit and tolerate something they wouldn’t do on their own.”

Tips From Seasoned Veterans
Other dietitians are the best resources. Seasoned dietitians have experience to offer for those interested in starting a mealtime support group. To gain experience before you begin planning your own group, observe a colleague’s group and watch how he or she maneuvers through tense situations. Keep group size small (four to eight) so you can give direct attention to a participant if needed. For a successful mealtime support group, adhere to a schedule. A clear agenda lets clients know exactly what to expect. Elicit input from group members to create rituals to mark their progress. Kelle’s last shared meal is pizza. She remarks, “It is a testimony to their commitment to accept food as just food. Every once in a while, someone will refuse, but by 10 weeks, they know it is coming and they are ready.”

Kelle’s best advice is to “stay calm and relaxed. Let your clients see that you understand their fear, but do not accept it as reality. Their fear is only the eating disorder getting in the way of the most normal human experience of breaking bread together.” Remind clients to, as Brennan says, “maintain the intention of eating rather than restricting or avoiding food.” Use relaxation techniques before the meal and plan distractions for mealtime. Focus on conversations that don’t involve food. “There needs to be humor, too. There’s always a lot of laughter in our dining room. Laughter is important. It shows that food doesn’t have to be painful,” Brennan says.

As far as professional compensation for these inventive treatment forums, payment spans the gamut. It is difficult to charge by the hour when at a restaurant and the length of the meal is unknown. Most dietitians charge per session and not on an hourly basis for mealtime groups and outings. Rates range from $50 to $100 per session, either billing per person or contracting out to an eating disorder clinic and charging per group. Few dietitians were found who provide mealtime support groups on a purely private practice basis. When a group is part of an intensive outpatient program, billing is usually folded into the program fee and insurance will cover some of the cost. Groups not affiliated with an intensive outpatient program are generally not covered by insurance. Mealtime support groups are an effective and original method to support clients and engage dietitians in exciting ways.

— Ilyse Simon, RD, CDN, is a freelance writer and has a private practice counseling eating disorders in upstate New York.